Provider Demographics
NPI:1073133104
Name:THANASOMBAT, EDWARD (PHARMD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:THANASOMBAT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12470 BOXWOOD TER
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-6905
Mailing Address - Country:US
Mailing Address - Phone:626-616-5904
Mailing Address - Fax:
Practice Address - Street 1:1500 DUARTE RD
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-3012
Practice Address - Country:US
Practice Address - Phone:626-359-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-18
Last Update Date:2020-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69632183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist